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2018 Pain Management Codes Posted on Website

Source: Emily Hill, PA, AAPM Coding Consultant
Date: January 10, 2018

The Coding and Reimbursement Committee has updated the coding information available on the AAPM website. New charts have been posted that include information concerning Medicare’s 2018 Relative Value Units (RVUs) for codes commonly reported by Pain Medicine Physicians. The title page provides links to CMS web pages that provide additional information and outlines the basis for the 2018 reimbursement rates.

The charts are organized according to the type of service (e.g. E/M, injections, radiology) with new and revised codes highlighted. As appropriate, some charts contain information indicating which codes include imaging guidance as well as which codes can be reported with the bilateral modifier. There is also a separate chart that lists all the new and revised codes for 2018. There were no significant changes impacting Pain Medicine Physicians.

The Relative Value Units in the charts reflect the combined RVUs for physician work, practice expense and professional liability (total RVUs). RVUs in the “facility” column are used to calculate payments in the hospital or other facility setting. RVUs in the “non-facility” column are used for services provided in a physician office.

View the charts of Common Pain Medicine Codes (login required)…

Bilateral Surgery and Medically Unlikely Edits

Source: Emily Hill, PA, AAPM Coding Consultant
Date: January 24, 2018

CMS has released a revised article that addresses the appropriate reporting of bilateral procedures and the potential impact of its rules known as “medically unlikely edits” (MUE) on reimbursement. The revised article provides more examples and details.

Bilateral procedures are those that are performed on paired organs or body structures. The use of the bilateral modifier 50 depends on the code descriptor and the bilateral “indicator” assigned by CMS. These indicators determine if reimbursement will be adjusted and paid at 150% of the Physician Fee Schedule (PFS) rate for the code. A bilateral payment indicator of 1 results in a payment adjustment. Codes assigned an indicator of 0, 2, or 3 will not result in a bilateral payment adjustment. When appropriate to append modifier 50, Medicare instructs that the CPT code be reported with modifier 50 as a single line on the claim and with 1 unit of service.

A MUE is the maximum number of units that can be reported for a particular CPT code by the same provider for the same patient on the same date of service. The MUEs are based on claims history and input from specialty societies on common clinical practice. MUEs may limit the number of units that can be reported with certain CPT codes. The reporting of bilateral procedures on more than one claim line or with more than one unit of service may exceed the number of allowed units and result in denials. It is therefore important to follow Medicare’s instructions when reporting bilateral procedures.

The bilateral indicators for CPT codes can be found in the PFS Relative Value Files.

The recently revised AAPM coding and reimbursement tool, Common Pain Medicine Codes (login required), also denotes which codes allow modifier 50.

Targeted Probe and Education (TPE)-New CMS Initiative

Source: Emily Hill, PA, AAPM Coding Consultant
Date: February 7, 2018

In October 2017 CMS launched a nationwide program to better target medical review, limit the number of medical records requested, and put an emphasis on education and assistance in correcting claims errors. The goal is to help identified providers and practices by having Medicare Administrative Contractors (MACs) work in person with the practice to identify specific errors and help correct them quickly.

Most providers will never need TPE. The program focuses on providers who have unusual billing patterns or billing practices that vary greatly from their peers. Practices will receive a letter if chosen for the program and CMS will request 20-40 claims with the accompanying documentation. If found compliant, then you will not be reviewed for at least one year on the identified topic. If denials are identified, you will be invited to a one-on-one education session and have 45 days to make changes and improve. The session will likely be held via teleconference or webinar and the provider will have the opportunity to ask questions about their specific claims as well as the underlying CMS policy.

View information on TPE. The page includes links to TPE Q&A documents as well as a one-page information sheet.

Specialty Societies and the AMA Successfully Challenge Anthem Payment Policy

Source: Emily Hill, PA, AAPM Coding Consultant
Date: March 7, 2018

The AMA and a number of specialty societies, including AAPM, were successful in preventing Anthem from applying a reimbursement reduction when an Evaluation and Management (E/M) service and a procedure were reported on the same day. The AMA and specialty societies responded to the planned change in payment policy by providing information regarding the valuation of procedure codes and the appropriate use of modifier 25. The AAPM was a signatory on the letter sent to Anthem.

Anthem had announced it would be applying a 50% reduction to an E/M service when reported on the same day as a procedure code. In December, it limited the reduction to 25% and gave an implementation date of March 1, 2108. In late February, Anthem announced, after receiving input from physician groups, it would not be applying any reduction when modifier 25 is appended to an E/M service performed on the same date as a procedure.

As you bill for your office-based services, it is important to remember that all procedure codes include the evaluation services necessary to perform the procedure, such as verifying medications and allergies (as appropriate), explaining the procedure, and obtaining consent. These services are included in the procedure code. Modifier 25 is used to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period. It is appropriate to use modifier 25 only when the E/M service is above and beyond the usual pre- and post- work of a procedure performed on the same day as the E/M service.

If you are receiving a reduction in reimbursement for E/M services reported with a procedure code from Anthem or other payers, please notify AAPM so that we can work with the AMA and other specialty societies to challenge these inappropriate policies.

New Medicare Card Transition Begins April 1

Source: Emily Hill, PA, AAPM Coding Consultant
Date: March 21, 2018

CMS will begin mailing new Medicare cards with the Medicare Beneficiary Identifier (MBI) in April 2018. The MBI on the new card is effective immediately unless the patient is new to Medicare. In that case, the start date will be on the card.

The new cards are being issued to comply with legislation requiring the removal of patient’s social security numbers from Medicare cards by April 2019. Cards will be mailed in waves based on geographic areas. View the new Medicare card mailing strategy. Targeted local outreach will be provided for beneficiaries and providers before mailing begins in each geographic location.

Your practices business systems must be able to accept the MBI for transactions, such as billing, claim status, eligibility status, and interactions, with your Medicare Administrative Contractor (MAC) contact centers. There will be a transition period during which you may exchange information using either the HICN or the MBI but you must be able to accept the MBI by April 2018. Cards issued to beneficiaries new to Medicare will only have a MBI.

Make sure you are prepared for this important transition. CMS has issued a fact sheet that contains additional information and links to other resources. View the fact sheet.

CMS Seeks Comments on Changes to E/M Documentation Guidelines

Source: Emily Hill, PA, AAPM Coding Consultant
Date: April 4, 2018

In the November 2017 Final Rule, CMS sought comments on potential updates to the Evaluation and Management (E/M) Documentation Guidelines. CMS indicated it was particularly interested in suggestions for initial changes to the history and exam components. CMS further suggested that medical decision making (MDM) and time are more important factors in distinguishing levels of service.

On March 21, 2018, CMS held a public listening session titled E/M Services: Documentation Guidelines and Burden Reduction Listening Session. The purpose of the session was to receive feedback from users regarding the current guidelines and suggestions for potential revisions. More specifically, the session asked questions regarding:

  • Ways to reduce the burden associated with the documentation of patient E&M visits.
  • Ways for CMS to seek input on approaches that other payers take to both the payment and the documentation regarding E&M visits.
  • The role of each currently required item in the E&M visits, specifically the history, physical exam, and medical decision making.
  • Documentation through changes to the underlying E&M code set.
  • Information on duplicative data entry in the medical record.
  • Information about changes to the E&M visits that are specialty specific.

Click here to access links to the audio recording, presentation and transcript.

CMS Releases Tool to Check Your MIPS Eligibility

Source: Emily Hill, PA, AAPM Coding Consultant
Date: April 18, 2018

CMS has recently released its updated MIPS Eligibility Lookup Tool. Enter your NPI number to determine if you need to participate in the MIPS program in 2018. Providers who meet the established low volume threshold do not need to participate.

CMS revised the volume threshold in 2018 to exclude more providers from the requirement to participate. Providers and groups are excluded from MIPS if they:

  • Billed $90,000 or less in Medicare Part B allowed charges for covered professional services under the Physician Fee Schedule (PFS) OR
  • Furnished covered professional services under the PFS to 200 or fewer Medicare Part B-enrolled beneficiaries

MIPS (Merit-based Incentive Payment System) is a key part of the CMS Quality Payment Program (QPP). The QPP replaces the Sustainable Growth Rate (SGR) formula for maintaining budget neutrality and streamlines prior quality programs (Physician Quality Reporting System, Meaningful Use Criteria, and the Value Based Modifier) into a single program. The intent of the QPP is to shift reimbursement from the volume of services provided toward a payment system that rewards clinicians for providing high quality services along with cost savings.

Information on the Quality Payment Program and MIPS can be found at: The Eligibility Tool can be found at:

New Medicare Beneficiary Identifiers (MBIs) Ready for Use

Source: Emily Hill, PA, AAPM Coding Consultant
Date: May 9, 2018

Some Medicare beneficiaries are receiving new Medicare cards with new Medicare Beneficiary Identifiers (MBIs). The MBIs are 11 characters in length and will use randomly selected numbers and upper case letters. The new cards and numbers are being issued in phases by geographic location. It is important to begin using the new MBIs for claims and other transactions once your patient receives the new Medicare card.

Medicare patients in the following locations will receive new cards beginning this month:

  • Delaware
  • District of Columbia
  • Maryland
  • Pennsylvania
  • Virginia
  • West Virginia
  • Alaska
  • American Samoa
  • California
  • Guam
  • Hawaii
  • Northern Mariana Islands
  • Oregon

CMS is encouraging practices to ask patients with Medicare for their new cards and to begin using the new number for all transactions. View the geographic phase-in schedule. All patients will receive new cards by April 2019.

No later than June 2018, CMS will have a Medicare Administrative Contractors’ secure MBI look-up tool so that practices can locate patients’ new MBIs. You can sign up for the portal to use the tool now.

Starting in October 2018 through the end of the transition period (April 1, 2018-December 31, 2019), Medicare will return the MBI on every remittance advice when you submit claims with valid and active HICNs (Health Insurance Claim Numbers).

What Is CDI and How Does It Impact You?

Source: Emily Hill, PA, AAPM Coding Consultant
Date: June 6, 2018

CDI (Clinical Documentation Improvement) has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. Hospitals began CDI programs as a response to the advent of DRGs (Diagnosis Related Groups) as a form of reimbursement. Most physicians have experienced the request for supplementary documentation to support additional or more specific ICD codes to enhance hospital reimbursement and data collection.

The ability to collect and track data has resulted in more robust and expanded CDI programs. Although CDI historically has been a hospital-based program, it is moving to physician practices as its importance is recognized. The impact of CDI today may be described as the completeness, consistency, organization and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision making. The overall goal of a CDI program is to improve clinical documentation, coding, and reimbursement.

From a reimbursement perspective, an effective CDI program can reduce denials and improve the appeals process using improved clinical documentation. Clinically, it results in a more useful medical record and more meaningful patient information and data.

Initiating a program in your practice requires thought and planning but it doesn’t have to be overwhelming. Over the next several months, we’ll focus on the steps of assessment, implementation and maintenance of an office-based CDI program. Improving documentation is inherently a good goal with down-stream benefits of improved reimbursement and an effective clinical record.

RUC Survey of CPT Codes for Injection of Somatic Nerves

Source: Emily Hill, PA, AAPM Coding Consultant
Date: June 20, 2018

Next week we will be contacting a random selection of members to participate in an important AMA/Specialty Society Relative Value Scale Update Committee (RUC) survey of physician work for several somatic and genicular nerve injection CPT codes. In the survey, you may be asked to provide information on several codes, two of which are new to CPT and six of which are established codes.

As you may know, the Medicare payment schedule is based on physician work, practice expense and professional liability insurance. Our society needs your help to assure relative values will be accurately and fairly presented to the Centers for Medicare and Medicaid. Your input in this survey is vital.

AAPM is conducting this survey for the RUC in partnership with several other medical specialties including the American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation, American Society of Anesthesiologists and the Spine Intervention Society. If you are a member of one or more of these additional societies, you may see a survey request from them (rather than from AAPM). In such instance, we ask that you treat their request as similarly vital. We will compile all relevant survey data from the partnering societies for our presentation to the AMA RUC.

For more information on understanding the RUC Survey instrument, please view this youtube video…

If you have any questions, please contact Emily Hill, AAPM Coding and Reimbursement Liaison, at: [email protected]

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